Provider Demographics
NPI:1194095984
Name:WILSON, LAUREN
Entity type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10645 N TATUM BLVD
Mailing Address - Street 2:200-629
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3068
Mailing Address - Country:US
Mailing Address - Phone:480-307-6790
Mailing Address - Fax:
Practice Address - Street 1:10645 N TATUM BLVD
Practice Address - Street 2:200-629
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3068
Practice Address - Country:US
Practice Address - Phone:480-307-6790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic